GASTROENTEROLOGY 2009;136:20032014
The Relationship Between Intestinal Microbiota and the Central Nervous
System in Normal Gastrointestinal Function and Disease
Stephen M. Collins Premysl Bercik
The Farncombe Family Digestive Health Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
Although many people are aware of the communica-
tion that occurs between the gastrointestinal (GI)
tract and the central nervous system, fewer know
about the ability of the central nervous system to
influence the microbiota or of the microbiotas influ-
ence on the brain and behavior. Within the GI tract,
the microbiota have a mutually beneficial relation-
ship with their host that maintains normal mucosal
immune function, epithelial barrier integrity, motil-
ity, and nutrient absorption. Disruption of this rela-
tionship alters GI function and disease susceptibility.
Animal studies suggest that perturbations of behav-
ior, such as stress, can change the composition of the
microbiota; these changes are associated with in-
creased vulnerability to inflammatory stimuli in the
GI tract. The mechanisms that underlie these alter-
ations are likely to involve stress-induced changes in
GI physiology that alter the habitat of enteric bacte-
ria. Furthermore, experimental perturbation of the
microbiota can alter behavior, and the behavior of
germ-free mice differs from that of colonized mice.
Gaining a better understanding of the relationship
between behavior and the microbiota could provide
insight into the pathogenesis of functional and in-
flammatory bowel disorders.
T he gut brain axis (GBA) is a bidirectional neurohu-
moral communication system that integrates brain
and gastrointestinal (GI) functions. The GBA has been im-
plicated in the pathophysiology of functional GI disorders,
and evidence is emerging for its role in the pathogenesis of
inflammatory disorders of the gut such as inflammatory
bowel disease (IBD). It would be a relatively straightforward
matter to integrate information about the intestinal micro-
biota with that of the GBA by simply reviewing literature on
interactions between flora and the GI tract. However, the
brain is the most influential organ within the axis, and
communication is bidirectional. Thus, it is important to
consider the influence of the brain on the microbial content
of the gut and, conversely, to examine the evidence showing
that the intestinal microbiota influences the brain and be-
havior. Investigation of the integration of the intestinal
microbiota into the GBA could improve the understanding
of the pathophysiology of both functional1 and inflamma-
tory2 bowel conditions.
The GBA contributes to homeostasis of several sys-
tems, including GI function, appetite, and weight con-
trol. Because GI motility and epithelial function are crit-
ical determinants of the habitat for the microbiota,
changes induced by the central nervous system or the GI
tract alter the habitat and perturb the intestinal micro-
biota.3 The longstanding observation that oral antibiot-
ics and laxatives ameliorate hepatic encephalopathy pro-
vides a potent reminder that the intestinal microbiota is
capable of influencing behavior, albeit under pathologic
conditions.4 Taken together, these observations provide a
framework for considering the integration of the intesti-
nal microbiota into the bidirectional GBA.
The Intestinal Microbiota
The gut contains a vast and complex microbial
ecosystem, comprising mainly bacteria, of which most are
strict anaerobes; it also includes fungi and viruses,57 but
only bacteria are considered in this review. Commensal
bacteria instruct the immune and physiologic systems
throughout life and are responsible for the presence of
inflammatory and immune cells in the healthy gut: so-
called physiologic or controlled inflammation. The
term physiologic inflammation refers to the presence of
Abbreviations used in this paper: ACTH, adrenocorticotrophic hor-
mone; GBA, gut brain axis; GI, gastrointestinal; IBD, inammatory
bowel disease; IBS, irritable bowel syndrome; SPF, specic pathogen-
free.
2009 by the AGA Institute
0016-5085/09/$36.00
doi:10.1053/j.gastro.2009.01.075
2004 COLLINS AND BERCIK
inflammatory cells in the mucosa and submucosa of the
healthy GI tract and reflects the presence and immuno-
logic accommodation (rather than immune tolerance) of
the intestinal microbiota. The microbiota serves the host
by protecting against pathogens, participating in the
intake nutrients from the diet, metabolizing certain
drugs and carcinogens, and influencing the absorption
and distribution of fat.8,9 The influence of the intestinal
microbiota extends beyond the GI tract, contributing to,
for example, pain perception in the skin10 and fat depo-
sition in the liver.11,12 Disruption of the symbiotic rela-
tionship between the microbiota and the GI tract, re-
ferred to as dysbiosis,13 perturbs host functions and, in
some cases, causes the expression of overt and serious
diseases such as IBD and Clostridium difficile colitis.14 16
Influence of the Microbiota on the GI
Tract
A strategy that is commonly used to investigate
interactions between the microbiota and the host is to
compare germ-free animals with those colonized with a
single strain or multiple strains of bacteria.17 The micro-
biota influences expression of a broad array of host genes.
A comparison of germ-free mice and mice colonized with
Bacteroides thetaiotaomicron, a prominent member of the
adult mouse and human gut microflora, showed that the
microbiota modulate the expression of genes that regu-
late nutrient absorption, mucosal barrier enhancement,
xenobiotic metabolism, and angiogenesis.18 Colonization
with B. thetaiotaomicron also induced a 2- to 5-fold in-
crease in mRNA encoding the synaptic vesicle-associated
protein-33,18 which is involved in synaptic neurotrans-
mission.19 This finding indicates that commensal bacte-
ria can influence the expression of genes whose products
influence function in the nervous system.
Comparisons of germ-free and colonized animals indi-
cate that, although crypt villous formation does not
require the presence of bacteria, epithelial cell differenti-
ation, including Paneth cell development, depends on the
microbiota in a way that serves both the host and resi-
dent bacteria (for review, see Falk et al17). Similarly, the
production and composition of mucin20 and the devel-
opment of 5-hydoxy-tryptaminesecreting enteroendo-
crine cells is influenced by the microbiota.21 Germ-free
rodents have an enlarged cecum, reflecting a gross dis-
turbance in GI motility22,23; its prompt reversal to normal
size on bacterial colonization identifies the microbiota as
a determinant of GI motility.24 26 The abnormal motility
of germ-free animals probably reflects a combination of
the lack of a mature enteroendocrine system,21 changes
in neurotransmission,18 and immaturity of the mucosal
immune system. The intestinal microbiota also has an
important influence on the imprinting, maturation, and
maintenance of the mucosal immune system (for reviews,
see Falk et al17 and Macpherson et al27). Inflammatory
cells are sparse in the germ-free intestine, and secondary
GASTROENTEROLOGY Vol. 136, No. 6
lymphoid structures are not developed. The significant
number of inflammatory cells in the lamina propria of
the colonized intestine of healthy hosts and the preser-
vation of normal epithelial structure and function are
reflections of the delicate and mutually beneficial rela-
tionship between the intestinal microbiota and the host.
Disruption of this balance, as a result of perturbation of
the microbiota by infection or antibiotics, results in dys-
biosis. The effect of dysbiosis on the host is determined
by the nature and magnitude of change in the bacteria
composition of the GI tract, as well as by host suscepti-
bilities.
Another strategy for assessing the effect of the intesti-
nal microbiota on host function is to perturb the com-
mensal bacteria with the use of oral antibiotics.28 A
combination of neomycin and bacitracin altered the mi-
crobiota in mice, substantially reducing the Lactobacillus
population.29 As shown in Figure 1, this resulted in a
small increment in myeloperoxidase (MPO) activity (a
measure of granulocytic inflammatory cell activity) with-
out causing tissue damage. This increment in physiologic
inflammation was accompanied by an increase in immu-
noreactive substance P, a sensory neurotransmitter, in
the intestinal wall. The functional consequence was an
increase in the visceromotor or pseudoaffective response
(abdominal wall contraction after colorectal balloon dis-
tension), a widely used measure of visceral pain.30 Thus,
perturbation of the microbiota produced a response pro-
file reminiscent of changes seen in some patients with
irritable bowel syndrome (IBS): subclinical inflammation
or immune activation and visceral hyperalgesia. Interest-
ingly, when the mice were gavaged with Lactobacillus pa-
racasei, the antibiotic-induced changes in inflammation,
neurotransmitter content, and the visceromotor response
improved.29 Because the antibiotic-induced changes in
the visceromotor response, immunoreactive substance P,
and myeloperoxidase activity could also be attenuated by
the administration of dexamethasone, it was concluded
that the changes in visceral perception were secondary to
the increase in the inflammatory or immune cell presence
induced by the dysbiosis.29 These results show that com-
mensal bacteria can influence primary afferent nerves in
the gut and serve as an example of a functional relation-
ship between the sensory component of nervous system
and the intestinal microbiota.
Influence of GI Physiology on the
Microbiota
Although the microbiota exert a broad influence
on host physiology, the converse is also true. Under
normal conditions, the GI tract provides a stable habitat
for commensal bacteria that supports its structural and
functional integrity (Figure 2A). Disturbance of normal
GI physiology destabilizes the habitat, resulting in
changes in its microbial composition. An example of this
is the change in the bacterial composition of the GI tract
May 2009
Figure 1. The effect of antibiotic-induced perturbation of the intestinal microbiota on myeloperoxidase activity (A), immune-reactive substance P in
the intestinal wall (B), and visceromotor response to balloon distension in mice (C) with or without treatment with Lactobacillus paracasei. AB,
antibiotic; ATB, antibiotic; AUC, area under the curve; Con, control; CRD, colorectal distension; LB, lactobacillus. Adapted with permission from
Verdu et al.29
after interruption of normal interdigestive motility in the
rat31 and in human beings.3 Changes in epithelial cell
physiology, mucous secretion, and intestinal barrier func-
tion are also likely to affect the mucosal-associated mi-
crobial ecosystem.17 The sympathetic nervous system fa-
cilitates the selective presentation of enteric bacteria to
the mucosal immune system.32 Norepinephrine-contain-
ing nerve fibers were identified in close proximity to the
epithelium that overlies lymphoid follicles in pig jeju-
num. Application of norepinephrine increased the up-
take of pathogenic bacteria into the follicles; this was
prevented by the adrenergic antagonist phentolamine.
However, the underlying cellular mechanisms were not
elucidated but probably involve the interaction of sym-
pathetic nerves with dendritic cells or specialized epithe-
lium to sample luminal bacteria and selectively take up
pathogenic bacteria for presentation to the mucosal im-
mune system.32
Evidence also suggests that the release of biologic
amines, such as norepinephrine, can influence the com-
position of the intestinal microbiota. This neurotrans-
mitter has been shown to stimulate the growth of patho-
genic and nonpathogenic Escherichia coli in vitro and to
influence their adherence to the mucosa.3335 Changes in
host physiology, initiated within the GI tract or by the
central nervous system, produce changes in the bacterial
composition of the GI tract. Alternatively, changes in the
microbiota, induced by infection or antibiotics, or other
events such as stress (see below) perturb physiologic
inflammation and GI physiology. A change in GI physi-
ology provides an altered habitat that in turn supports a
different microbiota. We propose that this cycle (Figure
2B) could be a basis for maintaining a state of GI dys-
function after perturbation of the microbiota; it could
also explain the development and persistence of dysbiosis
in conditions in which there is a primary disturbance of
GI physiology. So, the optimal therapy for these disor-
GUT MICROBES AND THE BRAIN 2005
ders would stabilize both host physiology and the bacte-
rial composition of the GI tract.
Ability of the Brain to Influence
Microbiota
Several animal studies suggest that psychological
stress alters GI flora, but each of these studies has limi-
tations. Tannock and Savage36 reported changes in GI
flora of mice stressed by deprivation of food, water, or
bedding. However, these environmental changes would
be expected to have a direct effect on the microbiota that
is independent from a stress response. Bailey and Coe37
used maternal separation to demonstrate a reduction in
lactobacilli for 7 days in infant rhesus monkeys; these
results should be interpreted cautiously because the stres-
sor limited maternal contact, and the analysis was limited
to the identification of culturable bacteria. An interesting
finding was that the reduction in lactobacilli appeared to
promote the emergence of enteric pathogens such as
Campylobacter jejuni. Additional studies showed the ability
of probiotics to ameliorate stress-induced changes in GI
function38 and to attenuate the observed reduction in
lactobacilli in maternally deprived rat pups.39 A recent
study showed that stress during early life (maternal sep-
aration) produced changes in the microbiota of the off-
spring, and this was associated with increased levels of
corticosterone and inflammatory cytokines40; the inves-
tigators speculated that this could reflect cytokine-in-
duced hyperresponsiveness of the hypothalamicpitu-
itary pathway in response to maternal separation. In
another study, maternal separation in mice was accom-
panied by an increase in intestinal permeability and a
vulnerability of the GI tract to inflammatory stimuli.41
Taken together, research conducted on offspring that
had been separated from their mothers show an in-
creased stress response, a systemic cytokine response,
increased intestinal permeability, and a shift in the bac-
2006 COLLINS AND BERCIK GASTROENTEROLOGY Vol. 136, No. 6

Figure 2. (A) The interrelationship of the intestinal microbiota and gastrointestinal physiology and inflammation in health (A) and in the presence of
intestinal dysbiosis (B). (A) The gastrointestinal tract under normal conditions provides a stable habitat for commensal bacteria that supports the
structural and functional integrity of the gut. The stable bacterial population in turn supports normal gut physiology. (B) Disturbance of (1) normal gut
physiology or (2) the microbiota destabilizes the habitat, resulting in change in physiologic inflammation which in turn alters physiology.

terial composition of the GI tract; these changes could
contribute to the increased susceptibility of the GI tract
to chemical and infectious inflammatory stimuli ob-
served in stress models. Because the stressor, separation
of mother and offspring, is applied at a time when the GI
tract is becoming colonized and host immune and phys-
iological systems are maturing, the extent to which these
findings can be applied to adult animals is limited. Re-
serpine-induced depression in adult mice was also accom-
panied by a vulnerability to GI tract inflammation,42 but
underlying mechanisms might differ from those ob-
served in the maternal separation model, and the effect of
the adult-onset depression on the microbiota has not yet
been studied.
There are several mechanisms by which stress can alter
the bacterial composition of the GI tract, including changes
in epithelial cell function and mucus secretion as well as
changes in GI motility.41,43,44 As described, release of nor-
epinephrine into the GI tract during stress might preferen-
tially stimulate the growth of specific strains of bacteria as
well as their ability to adhere to the mucosa.3234
Ability of Microbiota to Influence the
Brain and Behavior
The most compelling evidence of a GI microbe
brain interaction is the often dramatic improvement in
patients with hepatic encephalopathy after the adminis-
tration of oral antibiotics and laxatives.4 Although the
mechanistic basis for hepatic encephalopathy is incom-
pletely understood,45 there is some evidence from a rat
model of hepatic failure that certain bacteria can produce
a ligand for the benzodiazepine receptor that may con-
tribute to the encephalopathy.46 Observations in human
beings offer provocative but nevertheless weaker evidence
of communication between the microbiota and brain.
Patients with symptoms of depression have been shown
to have abnormal profiles of breath hydrogen excretion
after ingesting fructose and other sugars.47 Eliminating
fructose from the diet resulted in an improvement in
depression.48 In addition, fructose malabsorption was
accompanied by a reduction in plasma tryptophan.49
Fructose malabsorption provides substrate for rapid bac-
terial fermentation, resulting in changes in GI motility,
the mucosal biofilm, and the profile of the microbiota.50
A recent study showed that rats given Bifidobacteria infantis
for 14 days had increased plasma tryptophan levels, sug-
gesting that commensal bacteria have the ability to in-
fluence tryptophan metabolism.51 Thus, it is possible
that the reported linkages between carbohydrate malab-
sorption and depressive-like behavior reflect bacterial in-
terference with tryptophan metabolism.51 Culture- and
molecular-based analyses have shown changes in the mi-
crobiota of a small number of autistic patients, compared
with controls, with a greater prevalence of clostridial
species in autistic patients.52,53 In an uncontrolled trial,
vancomycin provided transient symptomatic relief to a
May 2009
limited number of children with late-onset autism.54
However, the relationship between the microbiota and
autistic behavior remains speculative.
Studies have shown that the brain responds to the
introduction of noninvasive pathogenic bacteria into the
cecum; brain stem nuclei are rapidly activated,55and there
is expression of anxiety-like behavior in mice.56,57 This
response is thought to be mediated by signals from the
afferent vagus nerve to the nucleus of the solitary tract
and the lateral parabrachial nucleus.57 No evidence of
inflammation was observed within the short time frame
of these studies.57,58 The composition of commensal bac-
teria was not assessed in these studies, but persistent and
major perturbations of the microbiota were unlikely,
given the short duration of the experiments and the
absence of an overt inflammatory response to pathogens,
which is critical for a sustained disruption of the micro-
biota.59,60
Studies in which mice were chronically infected with
Helicobacter pylori also show evidence of behavioral
changes. This infection produces changes in gastric phys-
iology that gradually improve after successful eradication
of H. pylori.61 These changes were accompanied by an
alteration in feeding behavior that persisted after eradica-
tion of infection and resolution of the changes in gastric
physiology. The persistent alteration in feeding behavior
was accompanied by changes in the hypothalamic appetite-
regulating peptide pro-opiomelanocortin.62 The mecha-
nisms that mediate changes in the brain and in behavior
during and after H. pylori infection are unknown but could
involve persistent immune activation in response to the
infection.63 A direct effect of H. pylori is unlikely, given the
persistence of the behavioral changes long after eradication.
The microbiota were not characterized in this model, but it
is interesting that changes in brain chemistry and behavior
were reversed by gavage of Lactobacillus rhamnosus and Lacto-
bacillus helveticus.62
Few studies have examined the brain and behavior in
germ-free hosts. However, a study by Sudo et al64 provided
insight into the role of commensal bacteria in the imprint-
ing of the hypothalamicpituitary response to stress. Dur-
ing mild restraint stress, the investigators observed an
increase in adrenocorticotrophic hormone (ACTH) and
corticosterone release in young germ-free mice, compared
with young, colonized specific pathogen-free (SPF) mice
(Figure 3). The response observed in germ-free mice was
specific to the stressor and did not occur during ether-
induced stress. The increases in stress-induced ACTH and
corticosterone release were completely reversed when germ-
free mice were colonized with B. infantis but only partially
reversed when germ-free mice were colonized with flora
from SPF mice. This observation is important because it
suggests that, within the flora of SPF mice, there are bacte-
ria that contribute to suppression of the ACTH response
and bacteria that increase this response; B. infantis clearly
belongs to the former category. The investigators also
GUT MICROBES AND THE BRAIN 2007
Figure 3. The effect of mild restraint stress on plasma adrenocortico-
trophic hormone (ACTH) concentrations in germ-free and colonized
young mice. Adapted with permission from Sudo et al.64
showed that enteropathogenic E. coli could increase the
stress response after mono-colonization of germ-free mice.
This effect of E. coli appears to involve attachment of the
bacteria to epithelial cells, because the effect was not ob-
served after mono-colonization with mutant E. coli that
lacked the translocation intimin receptor, which is critical
for the successful attachment to the epithelium. Interest-
ingly, the reversibility of the exaggerated stress response was
observed only in very young mice, indicating that there is a
critical period in which the plasticity of the neural regula-
tion of the stress response is sensitive to input from the
microbiota. Another important finding of Sudo et al64 was
the reduction in brain-derived neurotrophic factor expres-
sion and protein levels in the cortex and hippocampus of
germ-free mice compared with SPF mice. The brain-derived
neurotrophic factor regulates several aspects of brain activ-
ity, including mood and cognitive function. In a preliminary
report, McVeyNeufeld et al65 identified defects in contex-
tual learning in germ-free mice under stress and nonstress
conditions. They also found that germ-free mice exhibited
higher levels of anxiety when stressed (an exaggerated stress
response). Taken together, these reports demonstrate that
the intestinal microbiota influence the development of
brain responses to stress and influence cognitive function in
young mice.
Experimental perturbation of the intestinal microbiota
influences behavior in adult mice (Figure 4). In that
study,66 mice were given antibiotics (neomycin and bac-
itracin) for 7 days by gavage, along with the antifungal
agent primaricin to perturb the microbiota.28,29 Changes
in behavior, as assessed by the step-down test and the
light box dark box test, were observed in the antibiotic-
treated mice; these tests measure anxiety-like behavior or
timidity.67 Antibiotic-treated Balb/c mice showed a re-
2008 COLLINS AND BERCIK
Figure 4. The effect of antibiotic-induced perturbation of the micro-
biota in mice. Mice were treated with bacitracin, neomycin, and prima-
ricin28 by gavage for 7 days. Behavior was assessed in the step-down
test (left), and in the light box dark box test (middle and right). Re-
sponses of control mice are shown in the yellow bars and those of
antibiotic-treated mice are shown in the blue bars. Antibiotic-treated
mice showed a significantly lower latency to step-down, greater time
spent in the white box, and an increased number of crossovers be-
tween the light and dark boxes. ATB, antibiotics.
duced latency to step-down and increased activity in the
light box dark box test (Figure 4). In addition, the mice
given antibiotics spent more time exploring the light box,
compared with control mice. These findings indicate that
perturbation of the microbial content of the GI tract in
adult mice results in measurable changes in behavior.
The mice did not show fear or anxiety, but rather greater
activity after perturbation of the microbiota; this is not
consistent with a malaise effect of the gavaged antibiot-
ics. On the basis of these findings, we propose that
perturbation of the microbiota can influence behavior.
This is consistent with a recent study reporting behav-
ioral changes in mice in which the microbiota had been
perturbed by dietary alterations.68
The mechanisms by which the microbiota influence
behavior are unknown but could include immune-medi-
ated, neural, or humeral mechanisms. These mechanisms
are by no means mutually exclusive; it is likely that they
occur in series or in parallel. Immune mechanisms in-
clude activation of the innate immune response in the GI
tract. Toll-like receptors-2, -4, and -5 are down-regulated
in germ-free mice and become up-regulated during colo-
nization, implying interactions between these receptors
and the microbiota.69 Dendritic cells of the GI tract have
processes that breach the epithelial layer and interact
with commensal bacteria to induce the production of
immunoglobulin A by B lymphocytes and plasma cells.70
Secreted immunoglobulin A limits the penetration of the
epithelium by the microbiota. These mechanisms restrict
the inflammatory response to commensal bacteria to the
level seen under normal conditions (physiologic inflam-
mation). Dendritic cells are in close proximity to nerves
in the GI tract71; the sensory neuropeptide calcitonin-
gene-related peptide modulates dendritic cell function72
GASTROENTEROLOGY Vol. 136, No. 6
and might signal the presence of commensal bacteria to
the brain by the vagus nerve.71 There is close integration
of innate and adaptive responses, and the integrity of the
adaptive immune response is important for normal cog-
nitive function. Specifically, Kipnis et al73 showed that, in
mice, a deficit in peripheral T cells can result in cognitive
and behavioral impairment, although the origin of these
cells, and whether they cross the blood brain barrier or
signal from the periphery to influence behavior, is not
known.
The vagus nerve has an important role in signaling
from the GI tract to the brain and can be stimulated by
bacteria products such as endotoxins or inflammatory
cytokines such as interleukin-1 and tumor necrosis fac-
tor .74 The vagal response to stimulation by peripheral
inflammatory events is the suppression of proinflamma-
tory cytokine release from intestinal macrophages medi-
ated by the -7 subunit of the nicotinic acetylcholine
receptor on these cell.74,75 Interestingly, this response is
attenuated by the induction of depression in the
mouse.42 The introduction of noninvasive pathogens is
rapidly signaled to the brain, reflected by increased activ-
ity of vagus nuclei in the brain stem, and this is accom-
panied by anxiety-like behavior in mice.55,57,58 It is possi-
ble that perturbation of the microbiota is signaled in a
vagus-dependent manner, resulting in altered behavior.
For example, introduction of lactobacilli to the duode-
num of rats has been shown to increase gastric vagal
activity within minutes.76
How is the presence of commensal bacteria communi-
cated to the brain and how does it induce behavior
changes? Some studies indicate that soluble factors are
involved. Factor-S is a sleep-inducing substance that ac-
cumulates in the brain and body fluids of sleep-deprived
animals. It is unique because of its bacterial origin and is
derived from the bacterial cell wall. Studies suggest that
GI bacteria are an important source of Factor-S because
normal sleep patterns were disrupted after perturbation
of the microbiota with oral antibiotics.76,77 Commensal
bacteria also produce precursors of benzodiazepine re-
ceptor ligands that could contribute to encephalopathy
in a rat model of liver failure.46 Cognitive function im-
proved in patients with minimal hepatic encephalopathy
given Bifidobacterium longum with fructo-oligosaccharide
for 9 weeks. Although the mechanism of action is poorly
understood, B. longum might inhibit the activity of ure-
ase-positive commensal bacteria, which would reduce
ammonia levels or the production of other substances of
bacterial origin, including mercaptans and thioles.78
Probiotics
Probiotics are microbes (bacteria or yeast) that
confer health benefits to the host when administered in
sufficient quantity. They have been shown to influence
function in a variety of organs, including the nervous
May 2009
Figure 5. A hypothetical model describing the role of the intestinal microbiota in the pathogenesis of irritable bowel syndrome. In this model, known
risk factors for IBS that include gastroenteritis, antibiotic use, and stress produce changes in commensal bacteria and an increment in physiologic
inflammation. This leads to changes in gut function as a basis for abdominal symptom generation. Perturbation of the microbiota may contribute to
the behavioral profile seen in this condition.
system. Several studies report the effects of probiotics on
the GBA and in models of altered behavior.
In rats subjected to water-avoidance stress, intestinal
barrier function was reduced, and bacterial adherence to
the epithelium was increased. In addition, commensal
bacteria translocated across a leaky epithelial barrier,
ultimately reaching the mesenteric lymph nodes.79 Expo-
sure of rats to the probiotics L. helveticus and L. rhamnosus
prevented the stress-induced increase in adherence as well
as the translocation of commensal bacteria. Although it
was observed that the probiotics improved epithelial
function, it is not clear exactly how the probiotics func-
tioned in this model of the stress response.
Rat pups that experience maternal deprivation have a
significant increase in the visceromotor response to co-
lonic distension and increased GI paracellular permeabil-
ity, compared with controls. The probiotic L. paracasei
significantly improved stress-induced visceral pain and
restored normal GI permeability in the stressed rats. The
investigators concluded that this was mediated, at least
in part, by a soluble factor that was derived from the
probiotic. However, the mechanisms of action were not
identified.80
Another study investigated the antidepressant poten-
tial of a probiotics B. infantis given for 14 days to rats that
were chronically subjected to the forced swim test as a
stressor.51 This probiotic therapy resulted in a reduction
in levels of interferon , tumor necrosis factor , and
interleukin-6 after mitogen stimulation of peripheral
blood monocytes. In addition, there was a marked and
significant increase in plasma tryptophan and kynurenic
GUT MICROBES AND THE BRAIN 2009
acid in the probiotic-treated rats, compared with con-
trols. However, there was an unexplained reduction in the
concentration of 5-hydroxy-indole-acetic acid in the fron-
tal cortex and a decrease in dihydroxyphenylacetic acid, a
metabolite of dopamine, in the amygdaloid cortex in the
rats given the probiotics, and no improvement in the
forced swim test was observed. Although treatment failed
to influence behavior, the results of this study are impor-
tant because they show the antidepressant potential of
the bacterium B. infantis, primarily by virtue of its ability
to increase the serotonergic precursor, tryptophan.51
MicrobiotaGBA and Disease
Evidence is increasing for a role of the GBA in the
pathogenesis of IBD. Imbalance between the sympathetic
and parasympathetic outflow from the central nervous
system has been reported in patients with IBD81 83 and
may be associated with behavioral change. For example,
depression has been correlated with Crohns disease,
stress, and ulcerative colitis in separate groups of pa-
tients.84 A controlled study found an increased preva-
lence of depression in patients with IBD.85 It is difficult
to ascertain from human studies whether behavioral
changes are primary or occur as a result of the morbidity
of these conditions. Animal studies show that stress ex-
acerbates experimental colitis and that depression in-
creases susceptibility to inflammatory stimuli by impair-
ing vagal parasympathetic outflow to the gut.41,42,86
Given the experimental evidence that perturbation of the
microbiota alters behavior and that dysbiosis occurs in
2010 COLLINS AND BERCIK
Figure 6. The integration of the intestinal microbiota into the brain gut axis (GBA). Shown are the putative mechanisms whereby the brain may
influence the composition of the intestinal microbiota, and whereby the microbiota may influence the brain. The communication between these
systems is bidirectional. These are the components of the proposed bidirectional microbiota gut brain axis. CNS, central nervous system; EE,
entero-endocrine.
IBD, we speculate that dysbiosis could also contribute to
the behavioral changes reported in some patients with
IBD.
IBS is considered to be a disorder of the GBA, and
evidence is emerging of dysbiosis in patients with IBS.
Factors that are known to predispose individuals to IBS
include enteric infection, antibiotic use, and stress and
are also known to alter the bacterial composition of the
GI tract. Acute bacterial gastroenteritis is the strongest
risk factor known for the development of IBS.8790 Anti-
biotic usage in children or in the context of postinfective
IBS is also a risk factor for the development of IBS.91,92
Patients with IBS have an increased response to stress,93
and stress is also a predictor of IBS94 as well as a deter-
minant of symptom severity.95
Indirect evidence of dysbiosis in patients with IBS was
based on the analysis of fermentation profiles on stool or
breath samples. Some patients with IBS have demonstra-
ble qualitative or quantitative changes in fermentation
profiles compared with healthy controls,96 99 but the
interpretation of these findings remains controver-
sial.100,101 With the use of 16s rRNA analysis of stool
samples, a recent study found significant changes, par-
ticularly in Lactobacillus species, in patients with IBS pa-
tients compared with controls.102 A reduction in lactoba-
cilli was also observed in patients with diarrhea-
predominant IBS, whereas patients with constipation-
predominant IBS had increases in Veillonella species.103
Another study showed a greater temporal instability of
the microbiota during a 6-month period in patients with
GASTROENTEROLOGY Vol. 136, No. 6
IBS,104 but, unfortunately, the investigators did not cor-
relate these findings with symptom fluctuation. Never-
theless, taken together, these findings support the exis-
tence of intestinal dysbiosis in IBS.
In animal studies, dysbiosis has been shown to induce
low-grade inflammation that is not accompanied by tis-
sue damage,29 and it is plausible that dysbiosis is the
cause of the low-grade inflammation found in mucosal
biopsies in subsets of patients with IBS. The longstand-
ing notion that IBS represents a low-grade inflammatory
disorder105 is now supported by several lines of evidence,
including genetic studies,106,107 semiquantitative histo-
logic studies,108 as well as studies reporting increased
mediator production from inflammatory cells in the GI
wall109 and systemic circulation.110 We speculate that
dysbiosis is a determinant of immune activation and
low-grade inflammation in this subset of patients with
IBS.
The potential for the microbiota to produce small
increments in physiologic inflammation and thereby per-
turb GI and brain function prompts consideration of a
unifying hypothesis for IBS. Historically, IBS has been
viewed as a psychosomatic disorder, with emphasis on
psychiatric comorbidity and symptom reporting by pa-
tients with IBS, a central model of the pathogenesis of
IBS. During the past decade, another school of thought
has emerged, implicating gastroenteritis and low-grade
inflammation as mechanisms that underlie GI dysfunc-
tion and the symptoms of IBS, a peripheral model of IBS.
However, psychiatric comorbidity also occurs in patients
May 2009
with postinfective IBS, and low-grade inflammation is
found in patients with IBS with or without a history of
gastroenteritis. These observations prompt consideration
for a role of microbiotaGBA interactions in the patho-
physiology of IBS, particularly in patients with demon-
strable intestinal dysbiosis.
On the basis of the experimental data reviewed in
this article, we propose a model to incorporate intes-
tinal dysbiosis into a conceptual framework of IBS,
illustrated in Figure 5. In this model, recognized IBS
risk factors, such as acute gastroenteritis, antibiotic
therapy, or stress, produce intestinal dysbiosis and an
incremental increase in physiologic inflammation in
the colon that is subclinical but sufficient to alter
neuromuscular function (and thus produce GI symp-
toms). In addition, intestinal dysbiosis may contribute
to the behavioral profile of patients with IBS. This
construct requires testing in clinical studies.
In conclusion, experimental data and clinical observa-
tions support the integration of the intestinal microbiota
into the GBA (Figure 6). These include the bidirectional
interactions between the microbiota and GI physiology
and the associations between the microbiota and behav-
ior. Future research should focus on the contributions of
immunologic, neural, and biochemical or metabolic
pathways to the microbiotaGBA relationship. A better
understanding of these relationships will improve our
understanding of functional and inflammatory condi-
tions of the GI tract and of hepatic encephalopathy. This
knowledge may also prompt further exploration of the
role of the intestinal microbiota in behavioral illnesses
such as depression.
References
1. Chang L, Sundaresh S, Elliott J, et al. Dysregulation of the
hypothalamic-pituitary-adrenal (HPA) axis in irritable bowel syn-
drome. Neurogastroenterol Motil 2009 l21:149 159.
2. Stasi C, Orlandelli E. Role of the brain-gut axis in the pathophys-
iology of Crohns disease. Dig Dis 2008;26:156 166.
3. Vantrappen G, Jannssens J, Hellemans J, Ghoos Y. The interdi-
gestive motor complex of normal subjects and patients with
bacterial overgrowth of the small intestine. J Clin Invest 1977;
59:1158 1168.
4. Morgan MY. The treatment of chronic hepatic encephalopathy.
Hepatogastroenterology 1991;38:377387.
5. Eckburg PB, Bik EM, Bernstein CN, et al. Diversity of the human
intestinal microbial flora. Science 2005;308:16351638.
6. OHara AM, Shanahan F. Gut microbiota: mining for therapeutic
potential. Clin Gastroenterol Hepatol 2007;5:274 284.
7. Marchesi J, Shanahan F. The normal intestinal microbiota. Curr
Opin Infect Dis 2007;20:508 513.
8. Hooper LV, Gordon JI. Commensal host-bacterial relationships
in the gut. Science 2001;292:11151118.
9. Backhed F, Ley RE, Sonnenburg JL, Peterson DA, Gordon JI.
Host-bacterial mutualism in the human intestine. Science 2005;
307:19151920.
10. Amaral FA, Sachs D, Costa VV, et al. Commensal microbiota is
fundamental for the development of inflammatory pain. Proc
Natl Acad Sci U S A 2008;105:21932197.
GUT MICROBES AND THE BRAIN 2011
11. Dumas ME, Barton RH, Toye A, et al. Metabolic profiling reveals
a contribution of gut microbiota to fatty liver phenotype in insu-
lin-resistant mice. Proc Natl Acad Sci U S A 2006;103:12511
12516.
12. Backhed F, Ding H, Wang T, et al. The gut microbiota as an
environmental factor that regulates fat storage. Proc Natl Acad
Sci U S A 2004;101:15718 15723.
13. Hawrelak JA, Myers SP. The causes of intestinal dysbiosis: a
review. Altern Med Rev 2004;9:180 197.
14. Lepage P, Colombet J, Marteau P, Sime-Ngando T, Dore J,
Leclerc M. Dysbiosis in inflammatory bowel disease: a role for
bacteriophages? Gut 2008;57:424 425.
15. Jacobs NF Jr. Antibiotic-induced diarrhea and pseudomembra-
nous colitis. Postgrad Med 1994;95:111120.
16. McFarland LV. Epidemiology, risk factors and treatments for
antibiotic-associated diarrhea. Dig Dis 1998;16:292307.
17. Falk PG, Hooper LV, Midtvedt T, Gordon JI. Creating and main-
taining the gastrointestinal ecosystem: what we know and need
to know from gnotobiology. Microbiol Mol Biol Rev 1998;62:
11571170.
18. Hooper LV, Wong MH, Thelin A, Hansson L, Falk PG, Gordon JI.
Molecular analysis of commensal host-microbial relationships
in the intestine. Science 2001;291:881 884.
19. Skehel PA, Armitage BA, Bartsch D, et al. Proteins functioning in
synaptic transmission at the sensory to motor synapse of Aply-
sia. Neuropharmacology 1995;34:1379 1385.
20. Wold JK, Khan R, Midtvedt T. Intestinal glycoproteins of germ-
free rats. Chemical composition of intestinal and fecal mucus
from germfree rats fed a chemically defined diet. Acta Pathol
Microbiol Scand [B] Microbiol Immunol 1971;79:525530.
21. Uribe A, Alam M, Johansson O, Midtvedt T, Theodorsson E.
Microflora modulates endocrine cells in the gastrointestinal
mucosa of the rat. Gastroenterology 1994;107:1259 1269.
22. Abrams GD, Bishop JE. Effect of normal microbial flora on
gastrointestinal motility. Proc Soc Exp Biol (N Y) 1967;126:
301304.
23. Gustafsson BE, Midtvedt T, Strandberg K. Effects of microbial
contamination on the cecum enlargement of germfree rats.
Scand J Gastroenterol 1970;5:309 314.
24. Husebye E, Hellstrom PM, Sundler F, Chen J, Midtvedt T. Influ-
ence of microbial species on small intestinal myoelectric activity
and transit in germ-free rats. Am J Physiol Gastrointest Liver
Physiol 2001;280:G368 G380.
25. Husebye E, Hellstrom PM, Midtvedt T. Intestinal microflora stim-
ulates myoelectric activity of rat small intestine by promoting
cyclic initiation and aboral propagation of migrating myoelectric
complex. Dig Dis Sci 1994;39:946 956.
26. Caenepeel P, Janssens J, Vantrappen G, Eyssen H, Coremans
G. Interdigestive myoelectric complex in germ-free rats. Dig Dis
Sci 1989;34:1180 1184.
27. Macpherson AJ, Geuking MB, McCoy KD. Immune responses
that adapt the intestinal mucosa to commensal intestinal bac-
teria. Immunology 2005;115:153162.
28. van der WD, Sturm CA. Antibiotic decontamination of the diges-
tive tract of mice. Technical procedures. Lab Anim Care 1968;
18:110.
29. Verdu EF, Bercik P, Verma-Gandhu M, et al. Specific probiotic
therapy attenuates antibiotic induced visceral hypersensitivity in
mice. Gut 2006;55:182190.
30. Burton MB, Gebhart GF. Effects of intracolonic acetic acid on
responses to colorectal distension in the rat. Brain Res 1995;
672:7782.
31. Scott LD, Cahall DL. Influence of the interdigestive myoelectric
complex on enteric flora in the rat. Gastroenterology 1982;82:
737745.
2012 COLLINS AND BERCIK
32. Green BT, Lyte M, Kulkarni-Narla A, Brown DR. Neuromodulation
of enteropathogen internalization in Peyers patches from por-
cine jejunum. J Neuroimmunol 2003;141:74 82.
33. Chen C, Brown DR, Xie Y, Green BT, Lyte M. Catecholamines
modulate Escherichia coli O157:H7 adherence to murine cecal
mucosa. Shock 2003;20:183188.
34. Freestone PP, Williams PH, Haigh RD, Maggs AF, Neal CP, Lyte
M. Growth stimulation of intestinal commensal Escherichia coli
by catecholamines: a possible contributory factor in trauma-
induced sepsis. Shock 2002;18:465 470.
35. Lyte M. The biogenic amine tyramine modulates the adherence
of Escherichia coli O157:H7 to intestinal mucosa. J Food Prot
2004;67:878 883.
36. Tannock GW, Savage DC. Influences of dietary and environmen-
tal stress on microbial populations in the murine gastrointesti-
nal tract. Infect Immun 1974;9:591598.
37. Bailey MT, Coe CL. Maternal separation disrupts the integrity of
the intestinal microflora in infant rhesus monkeys. Dev Psycho-
biol 1999;35:146 155.
38. Eutamene H, Bueno L. Role of probiotics in correcting abnor-
malities of colonic flora induced by stress. Gut 2007;56:1495
1497.
39. Gareau MG, Jury J, MacQueen G, Sherman PM, Perdue MH.
Probiotic treatment of rat pups normalises corticosterone re-
lease and ameliorates colonic dysfunction induced by maternal
separation. Gut 2007;56:15221528.
40. OMahony SM, Marchesi JR, Scully P, et al. Early life stress
alters behavior, immunity, and microbiota in rats: implications
for irritable bowel syndrome and psychiatric illnesses. Biol Psy-
chiatry 2009;65:263267.
41. Varghese AK, Verdu EF, Bercik P, et al. Antidepressants atten-
uate increased susceptibility to colitis in a murine model of
depression. Gastroenterology 2006;130:17431753.
42. Ghia JE, Blennerhassett P, Collins SM. Impaired parasympa-
thetic function increases susceptibility to inflammatory bowel
disease in a mouse model of depression. J Clin Invest 2008;
118:2209 2218.
43. Groot J, Bijlsma P, Van Kalkeren A, Kiliaan A, Saunders P,
Perdue M. Stress-induced decrease of the intestinal barrier
function. The role of muscarinic receptor activation. Ann N Y
Acad Sci 2000;915:237246.
44. Rubio CA, Huang CB. Quantification of the sulphomucin-produc-
ing cell population of the colonic mucosa during protracted
stress in rats. In Vivo 1992;6:81 84.
45. Williams R. Review article: bacterial flora and pathogenesis in
hepatic encephalopathy. Aliment Pharmacol Ther 2007;25(Suppl
1):1722.
46. Yurdaydin C, Walsh TJ, Engler HD, et al. Gut bacteria provide
precursors of benzodiazepine receptor ligands in a rat model of
hepatic encephalopathy. Brain Res 1995;679:42 48.
47. Ledochowski M, Widner B, Sperner-Unterweger B, Propst T,
Vogel W, Fuchs D. Carbohydrate malabsorption syndromes and
early signs of mental depression in females. Dig Dis Sci 2000;
45:12551259.
48. Ledochowski M, Widner B, Bair H, Probst T, Fuchs D. Fructose-
and sorbitol-reduced diet improves mood and gastrointestinal
disturbances in fructose malabsorbers. Scand J Gastroenterol
2000;35:1048 1052.
49. Ledochowski M, Widner B, Murr C, Sperner-Unterweger B, Fuchs D.
Fructose malabsorption is associated with decreased plasma tryp-
tophan. Scand J Gastroenterol 2001;36(4):367371.
50. Gibson PR, Newnham E, Barrett JS, Shepherd SJ, Muir JG.
Review article: fructose malabsorption and the bigger picture.
Aliment Pharmacol Ther 2007;25(4):349 363.
51. Desbonnet L, Garrett L, Clarke G, Bienenstock J, Dinan TG. The
probiotic Bifidobacteria infantis: an assessment of potential
GASTROENTEROLOGY Vol. 136, No. 6
antidepressant properties in the rat. J Psychiatr Res 2008;43:
164 174.
52. Finegold SM, Molitoris D, Song Y, et al. Gastrointestinal micro-
flora studies in late-onset autism. Clin Infect Dis 2002;
35(Suppl):S6 S16.
53. Song Y, Liu C, Finegold SM. Real-time PCR quantitation of
clostridia in feces of autistic children. Appl Environ Microbiol
2004;70(11):6459 6465.
54. Sandler RH, Finegold SM, Bolte ER, et al. Short-term benefit
from oral vancomycin treatment of regressive-onset autism.
J Child Neurol 2000;15(7):429 435.
55. Wang X, Wang BR, Zhang XJ, Xu Z, Ding YQ, Ju G. Evidences for
vagus nerve in maintenance of immune balance and transmis-
sion of immune information from gut to brain in STM-infected
rats. World J Gastroenterol 2002;8:540 545.
56. Goehler LE, Lyte M, Gaykema RP. Infection-induced viscerosensory
signals from the gut enhance anxiety: implications for psychoneu-
roimmunology. Brain Behav Immun 2007;21:721726.
57. Gaykema RP, Goehler LE, Lyte M. Brain response to cecal
infection with Campylobacter jejuni: analysis with Fos immuno-
histochemistry. Brain Behav Immun 2004;18:238 245.
58. Lyte M, Li W, Opitz N, Gaykema RP, Goehler LE. Induction of
anxiety-like behavior in mice during the initial stages of infection
with the agent of murine colonic hyperplasia Citrobacter roden-
tium. Physiol Behav 2006;89:350 357.
59. Stecher B, Robbiani R, Walker AW, et al. Salmonella enterica
serovar Typhimurium exploits inflammation to compete with the
intestinal microbiota. PLoS Biol 2007;5:21772189.
60. Lupp C, Robertson ML, Wickham ME, et al. Host-mediated
inflammation disrupts the intestinal microbiota and promotes
the overgrowth of Enterobacteriaceae. Cell Host Microbe 2007;
2:204.
61. Bercik P, De Giorgio R, Blennerhassett P, Verdu EF, Barbara G,
Collins SM. Immune-mediated neural dysfunction in a murine
model of chronic Helicobacter pylori infection. Gastroenterology
2002;123:12051215.
62. Bercik P, Verdu EF, Foster JA, et al. Role of gut-brain axis in
persistent abnormal feeding behavior in mice following eradica-
tion of Helicobacter pylori infection. Am J Physiol Regul Integr
Comp Physiol 2009;296:R587R594.
63. Verdu EF, Bercik P, Huang XX, et al. The role of luminal factors
in the recovery of gastric function and behavioral changes after
chronic Helicobacter pylori infection. Am J Physiol Gastrointest
Liver Physiol 2008;295:G664 G670.
64. Sudo N, Chida Y, Aiba Y, et al. Postnatal microbial colonization
programs the hypothalamic-pituitary-adrenal system for stress
response in mice. J Physiol 2004;558:263275.
65. McVeyNeufeld KA, Bienenstock J, JA Foster. The impact of
intestinal microbiota on anxiety like behavior [abstract]. Neuro-
gastroenterol Motil 2008;20(Suppl2):125.
66. Denou E, Bercik P, Collins SM. Perturbation of the intestinal
microbiota alters behavior in mice. Gastroenterology DDW (in
press).
67. Crawley JN. Behavioral phenotyping of rodents. Comp Med
2003;53:140 146.
68. Li W, Dowd SE, Scurlock B, Acosta-Martinez V, Lyte M. Memory
and learning behavior in mice is temporally associated with
diet-induced alterations in gut bacteria. Physiol Behav 2009;96:
557567.
69. Lundin A, Bok CM, Aronsson L, et al. Gut flora, Toll-like receptors
and nuclear receptors: a tripartite communication that tunes in-
nate immunity in large intestine. Cell Microbiol 2008;10:1093
1103.
70. Macpherson AJ, Slack E. The functional interactions of commen-
sal bacteria with intestinal secretory IgA. Curr Opin Gastroen-
terol 2007;23:673 678.
May 2009
71. Goehler LE, Gaykema RP, Nguyen KT, et al. Interleukin-1beta in
immune cells of the abdominal vagus nerve: a link between the
immune and nervous systems? J Neurosci 1999;19:2799 2806.
72. Hosoi J, Murphy GF, Egan CL, et al. Regulation of Langerhans
cell function by nerves containing calcitonin gene-related pep-
tide. Nature 1993;363:159 163.
73. Kipnis J, Cohen H, Cardon M, Ziv Y, Schwartz M. T cell deficiency
leads to cognitive dysfunction: implications for therapeutic vac-
cination for schizophrenia and other psychiatric conditions. Proc
Natl Acad Sci U S A 2004;101:8180 8185.
74. Borovikova LV, Ivanova S, Zhang M, et al. Vagus nerve stimula-
tion attenuates the systemic inflammatory response to endo-
toxin. Nature 2000;405:458 462.
75. Ghia JE, Blennerhassett P, Kumar-Ondiveeran H, Verdu EF, Col-
lins SM. The vagus nerve: a tonic inhibitory influence associated
with inflammatory bowel disease in a murine model. Gastroen-
terology 2006;131:11221130.
76. Tanida M, Yamano T, Maeda K, Okumura N, Fukushima Y, Nagai K.
Effects of intraduodenal injection of Lactobacillus johnsonii La1 on
renal sympathetic nerve activity and blood pressure in urethane-
anesthetized rats. Neurosci Lett 2005;389(2):109 114.
77. Brown R, Price RJ, King MG, Husband AJ. Are antibiotic effects
on sleep behavior in the rat due to modulation of gut bacteria?
Physiol Behav 1990;48:561565.
78. Malaguarnera M, Greco F, Barone G, Gargante MP, Malaguarn-
era M, Toscano MA. Bifidobacterium longum with fructo-oligo-
saccharide (FOS) treatment in minimal hepatic encephalopathy:
a randomized, double-blind, placebo-controlled study. Dig Dis
Sci 2007;52:3259 3265.
79. Zareie M, Johnson-Henry K, Jury J, et al. Probiotics prevent
bacterial translocation and improve intestinal barrier function in
rats following chronic psychological stress. Gut 2006;55:1553
1560.
80. Eutamene H, Lamine F, Chabo C, et al. Synergy between Lac-
tobacillus paracasei and its bacterial products to counteract
stress-induced gut permeability and sensitivity increase in rats.
J Nutr 2007;137:19011907.
81. Lindgren S, Stewenius J, Sjlund K, Lilja B, Sundkvist G. Auto-
nomic vagal nerve dysfunction in patients with ulcerative colitis.
Scand J Gastroenterol 1993;28:638 642.
82. Lindgren S, Lilja B, Rosn I, Sundkvist G. Disturbed autonomic
nerve function in patients with Crohns disease. Scand J Gas-
troenterol 1991;26:361366.
83. Ganguli SC, Kamath MV, Redmond K, et al. A comparison of
autonomic function in patients with inflammatory bowel disease
and in healthy controls. Neurogastroenterol Motil 2007;19:961
967.
84. Maunder RG, Levenstein S. The role of stress in the develop-
ment and clinical course of inflammatory bowel disease: epide-
miological evidence. Curr Mol Med 2008;8:247252.
85. Walker JR, Ediger JP, Graff LA, et al. The Manitoba IBD cohort
study: a population-based study of the prevalence of lifetime
and 12-month anxiety and mood disorders. Am J Gastroenterol
2008;103:1989 1997.
86. Qiu BS, Vallance BA, Blennerhassett PA, Collins SM. The role of
CD4 lymphocytes in the susceptibility of mice to stress-in-
duced reactivation of experimental colitis. Nat Med 1999;5:
1178 1182.
87. Marshall JK, Thabane M, Garg AX, Clark WF, Salvadori M, Collins
SM. Incidence and epidemiology of irritable bowel syndrome
after a large waterborne outbreak of bacterial dysentery. Gas-
troenterology 2006;131:445 450.
88. Parry SD, Stansfield R, Jelley D, et al. Does bacterial gastroen-
teritis predispose people to functional gastrointestinal disor-
ders? A prospective, community-based, case-control study. Am J
Gastroenterol 2003;98:1970 1975.
GUT MICROBES AND THE BRAIN 2013
89. Spiller RC. Estimating the importance of infection in IBS. Am J
Gastroenterol 2003;98:238 241.
90. Rodriguez LA, Ruigomez A. Increased risk of irritable bowel
syndrome after bacterial gastroenteritis: cohort study. BMJ
1999;318:565566.
91. Ruigomez A, Garcia Rodriguez LA, Panes J. Risk of irritable
bowel syndrome after an episode of bacterial gastroenteritis in
general practice: influence of comorbidities. Clin Gastroenterol
Hepatol 2007;5:465 469.
92. Mendall MA, Kumar D. Antibiotic use, childhood affluence and
irritable bowel syndrome (IBS). Eur J Gastroenterol Hepatol
1998;10:59 62.
93. Mayer EA, Naliboff BD, Chang L, Coutinho SV. V. Stress and
irritable bowel syndrome. Am J Physiol Gastrointest Liver Physiol
2001;280:G519 G524.
94. Fujii Y, Nomura S. A prospective study of the psychobehavioral
factors responsible for a change from non-patient irritable bowel
syndrome to IBS patient status. Biopsychosoc Med 2008;2:16.
95. Blanchard EB, Lackner JM, Jaccard J, et al. The role of stress in
symptom exacerbation among IBS patients. J Psychosom Res
2008;64:119 128.
96. King TS, Elia M, Hunter JO. Abnormal colonic fermentation in
irritable bowel syndrome. Lancet 1998;352:11871189.
97. Lin HC. Small intestinal bacterial overgrowth: a framework for
understanding irritable bowel syndrome. JAMA 2004;292:852
858.
98. Pimentel M, Lezcano S. Irritable bowel syndrome: bacterial over-
growthwhats known and what to do. Curr Treat Options Gas-
troenterol 2007;10:328 337.
99. Treem WR, Ahsan N, Kastoff G, Hyams JS. Fecal short-chain
fatty acids in patients with diarrhea-predominant irritable bowel
syndrome: in vitro studies of carbohydrate fermentation. J Pe-
diatr Gastroenterol Nutr 1996;23:280 286.
100. Dear KL, Elia M, Hunter JO. Do interventions which reduce
colonic bacterial fermentation improve symptoms of irritable
bowel syndrome? Dig Dis Sci 2005;50:758 766.
101. Vanner S. The small intestinal bacterial overgrowth. Irritable
bowel syndrome hypothesis: implications for treatment. Gut
2008;57:13151321.
102. Kassinen A, Krogius-Kurikka L, Makivuokko H, et al. The fecal
microbiota of irritable bowel syndrome patients differs signifi-
cantly from that of healthy subjects. Gastroenterology 2007;
133:24 33.
103. Malinen E, Rinttila T, Kajander K, et al. Analysis of the fecal
microbiota of irritable bowel syndrome patients and healthy
controls with real-time PCR. Am J Gastroenterol 2005;100:
373382.
104. Maukonen J, Satokari R, Matto J, Soderlund H, Mattila-Sandholm
T, Saarela M. Prevalence and temporal stability of selected clos-
tridial groups in irritable bowel syndrome in relation to predominant
faecal bacteria. J Med Microbiol 2006;55:625 633.
105. Collins SM. Is the irritable gut an inflamed gut? Scand J Gas-
troent Suppl 1992;192:102105.
106. Gonsalkorale WM, Perrey C, Pravica V, Whorwell PJ, Hutchin-
son IV. Interleukin 10 genotypes in irritable bowel syndrome:
evidence for an inflammatory component? Gut 2003;52:
9193.
107. van der Veek PP, van den BM, de Kroon YE, Verspaget HW,
Masclee AA. Role of tumor necrosis factor-alpha and interleu-
kin-10 gene polymorphisms in irritable bowel syndrome. Am J
Gastroenterol 2005;100:2510 2516.
108. Barbara G, Stanghellini V, De Giorgio R, et al. Activated mast
cells in proximity to colonic nerves correlate with abdominal
pain in irritable bowel syndrome. Gastroenterology 2004;
126:693702.
2014 COLLINS AND BERCIK
109. Barbara G, Wang B, Stanghellini V, et al. Mast cell-dependent
excitation of visceral-nociceptive sensory neurons in irritable
bowel syndrome. Gastroenterology 2007;132:26 37.
110. OMahony L, McCarthy J, Kelly P, et al. Lactobacillus and bi-
fidobacterium in irritable bowel syndrome: symptom responses
and relationship to cytokine profiles. Gastroenterology 2005;
128:541551.
Received November 7, 2008. Accepted January 25, 2009.
Reprint requests
Address requests for reprints to: Stephen M. Collins, MB.BS,
FRCPC, Faculty of Health Sciences, Room 2E17, McMaster
University, 1200 Main Street West, Hamilton, ON, Canada L8N 3Z5.
e-mail: scollins@mcmaster.ca; fax: (905) 524-1346.
GASTROENTEROLOGY Vol. 136, No. 6
Acknowledgments
The authors thank Dr Elena F. Verdu, Emmanuel Denou, PhD, and
Jean-Eric Ghia, PhD, for their contributions to the work shown in this
manuscript.
Conicts of interest
The authors disclose the following: Dr S.M. Collins received a
grant in aid from the Nestle Research Institute, Switzerland, and
from Institut Rossel, Montreal, Canada. Dr P. Bercik received a
grant in aid from the Nestle Research Institute, Switzerland.
Funding
The work was supported primarily by the Canadian Institutes of
Health Research (CIHR) and by unrestricted grants from the Nestle
Research Institute, Switzerland, and Institut Rosell, Montreal,
Canada.